A Budding Emergencist
Thursday, December 28, 2006
Sigh.
I've enabled word-verification for comments after deleting dozens of spam comments.
I had a dream the other night about how to get back at them spam commenters. I thought about becoming a hacker, an uber-h4XX0R, dealing out DOS's attacks to the sites the spams link to. We would be locked in epic combat, me versus the spammers, using ever-more sophisticated tools to punish the wicked spam-commenters and protect the innocent bloggers.
Then I woke up.
Happy New Year! ¶ 9:26 PM 2 comments
I had a dream the other night about how to get back at them spam commenters. I thought about becoming a hacker, an uber-h4XX0R, dealing out DOS's attacks to the sites the spams link to. We would be locked in epic combat, me versus the spammers, using ever-more sophisticated tools to punish the wicked spam-commenters and protect the innocent bloggers.
Then I woke up.
Happy New Year! ¶ 9:26 PM 2 comments
Friday, December 22, 2006
Plugging a Useful Meme
Imagine this was your drug rep.
I was over at #1 Dinosaur's, and he said he'd just been over at DB's, guess what he said: Just say no to drug reps!
And I thought I was all alone. (US site down? WTF?)
TANSTAAFL, people.
As a doctor and prescription-writer, I consider myself a judge of what medications to give, or not. "And you shall take no gift; for a gift blinds those who have sight, and perverts the words of the righteous." -Exodus 23:8
And now I'll repost (they're that good) Robert Caldini's "Six Weapons of Influence".
"* Reciprocation - People tend to return a favor. Thus, the pervasiveness of free samples in marketing. In his conferences, he often uses the example of Ethiopia providing thousands of dollars in humanitarian aid to mexico just after the 1985 earthquake, in return to past gestures Mexico had with Ethiopia.
* Commitment and Consistency - If people agree to make a commitment toward a goal or idea, they are more likely to honor that commitment. However, if the incentive or motivation is removed after they have already agreed, they will continue to honor the agreement. For example, in car sales, suddenly raising the price at the last moment works because the buyer has already decided to buy. See cognitive dissonance.
* Social Proof - People will do things that they see other people are doing. For example, in one experiment, one or more accomplices would look up into the sky; the more accomplices the more likely people would look up into the sky to see what they were seeing. At one point this experiment aborted, as so many people were looking up, that they stopped traffic. See conformity, and the Asch conformity experiments.
* Authority - People will tend to obey authority figures, even if they are asked to perform objectionable acts. Cialdini cites incidents, such as the Milgram experiments in the early 1960s and the My Lai massacre.
* Liking - People are easily persuaded by other people that they like. Cialdini cites the marketing of Tupperware in what might now be called viral marketing. People were more likely to buy if they liked the person selling it to them. Some of the many biases favoring more attractive people are discussed. See physical attractiveness stereotype.
* Scarcity - Perceived scarcity will generate demand. For example, saying offers are available for a “limited time only” encourages sales."
Strewth!
--dex.
P.S. Wikipedia is having a pledge drive a la NPR. Reflecting on my heavy use of it, I gave $20 bucks. You should too. It's one of the best things about teh intarweb. ¶ 7:32 PM 2 comments
Imagine this was your drug rep.
I was over at #1 Dinosaur's, and he said he'd just been over at DB's, guess what he said: Just say no to drug reps!
And I thought I was all alone. (US site down? WTF?)
TANSTAAFL, people.
As a doctor and prescription-writer, I consider myself a judge of what medications to give, or not. "And you shall take no gift; for a gift blinds those who have sight, and perverts the words of the righteous." -Exodus 23:8
And now I'll repost (they're that good) Robert Caldini's "Six Weapons of Influence".
"* Reciprocation - People tend to return a favor. Thus, the pervasiveness of free samples in marketing. In his conferences, he often uses the example of Ethiopia providing thousands of dollars in humanitarian aid to mexico just after the 1985 earthquake, in return to past gestures Mexico had with Ethiopia.
* Commitment and Consistency - If people agree to make a commitment toward a goal or idea, they are more likely to honor that commitment. However, if the incentive or motivation is removed after they have already agreed, they will continue to honor the agreement. For example, in car sales, suddenly raising the price at the last moment works because the buyer has already decided to buy. See cognitive dissonance.
* Social Proof - People will do things that they see other people are doing. For example, in one experiment, one or more accomplices would look up into the sky; the more accomplices the more likely people would look up into the sky to see what they were seeing. At one point this experiment aborted, as so many people were looking up, that they stopped traffic. See conformity, and the Asch conformity experiments.
* Authority - People will tend to obey authority figures, even if they are asked to perform objectionable acts. Cialdini cites incidents, such as the Milgram experiments in the early 1960s and the My Lai massacre.
* Liking - People are easily persuaded by other people that they like. Cialdini cites the marketing of Tupperware in what might now be called viral marketing. People were more likely to buy if they liked the person selling it to them. Some of the many biases favoring more attractive people are discussed. See physical attractiveness stereotype.
* Scarcity - Perceived scarcity will generate demand. For example, saying offers are available for a “limited time only” encourages sales."
Strewth!
--dex.
P.S. Wikipedia is having a pledge drive a la NPR. Reflecting on my heavy use of it, I gave $20 bucks. You should too. It's one of the best things about teh intarweb. ¶ 7:32 PM 2 comments
Sunday, December 17, 2006
Nurse, May I Have A Word?
Hulk is getting ANGRY!
J/K.
In response to Doctor, May I Have A Word?:
First off, good post by Emergiblog's Kim McAllister.
Second off, much respect.
Third--sharps. I agree wholeheartedly. I absolutely endeavor to police my sharps myself every time. I even get a little miffed if somebody wants to "help" by picking up my sharps. This messes up my count. I don't want to be stripping the bed only to find out my sharps were picked up without telling me. Anyway, go ahead and remind me. I do not mind. I will thank you for reminding me. Safety first. Go ahead and remind me to wash my hands, put in orders, finish the paperwork, too. I don't mind.
"Please let me push the drugs, doctor." I had a learning experience emphasizing this when I first pushed 5 of morphine. Silly me, I simply unplugged the I.V., fitted the syringe into the clave, and pushed 1 ml of morphine directly into the patient's hand I.V. I watched, fascinated, as the patient's arm turned bright red, creeping up from the hand. My previously AAOx3 patient said, "ooooh, I'm itchy," and again I watched in amazement my patient's rapidly deteriorating mental status. I stood there like a statue, transfixed by this metamorphosis, until a small, still voice echoed in my head--"Histamine release!". I snapped back to reality, and calmly asked the same nurse who had given me the morphine, "25 of benadryl I.V., please. Stat." The entire episode lasted about a minute, and the patient just as dramatically recovered after Benadryl was given. Lesson learned. No blood, no foul. Omerta!
So yeah, you should give the meds, nurse. Not only to avoid above rookie-type mistakes, but also for the sake of documentation.
However, don't look at me crosseyed when I want 4mg of Versed "to go," (accompanying delirious patient to MRI) or "5/2/1" mg of Haldol/Ativan/Cogentin "just in case," (okay, I'll evaluate the 250 pound gorilla in florid psychosis. No problem!) or the 20 mg of labetalol "for the road," that I want to be armed with as I escort my 92 year old pretzel with Afib/RVR to telemetry.
Sorry if I bogart the chart at times. I always try to ask. Doesn't really apply in my ER cuz we got a pretty good EHR, with patient tracking and results reporting in-line with nurse's and doctor's notes, in real time. Slam!
Respect for the triage and intake ritual. This usually isn't a problem for me--we are usually so swamped, I am 8 patients behind all the time--no chance to be chomping at the bit for more work. Almost a non sequitur where I work.
You get first crack at the new patients coming in. Believe me, I am grateful you do this--forewarned is forearmed. Vital signs are vital, as they say. In fact, unless the patient is crashing right there, I want you to spend MORE time doing this. More than once I've been blindsided by "historicus alternans," or inappropriate triage acuity.
On my last shift in the ER as an intern this year, I picked up a 65 year old with a chief complaint of "don't feel well", triaged to low acuity. The patient had been waiting 4 hours or so. The history was almost impossible to obtain--the patient was verbal and calm, but confused. Relatives were in other states, and no primary care doctor could be elicited. No significant medical history or medication list could be elicited. The only corroborating story coming from the helpful but clueless neighbor who found the patient.
The patient's answers to all my questions were noncommittal, vague, or just plain "I don't know". Unsure of what I was looking for, I proceeded with my exam, which revealed an obvious global cognitive deficit, and mild motor weaknesses in the right upper and lower extremities. Patient in no acute distress. Vital signs rock solid.
Puzzled, I presented the patient to my attending, lamely attempting a synopsis of the patient's present illness, with a working diagnosis of dementia, geared towards my plan of "social" admission until home care or nursing home placement could be arranged. As my attending stared at me in disbelief, I became painfully aware of how pathetic my assesment really was.
"Confused with unilateral weakness, huh? What's her baseline?" my attending snapped.
"Uh, she lives at home by herself."
"Do you think that lady," nodding towards the patient, "could shop? Clean? Cook for herself?"
"Uh, no."
"So it's fair to say that this is an acute change in functioning."
"Yes." I surrender!
"Did it occur to you that this patient had a stroke?"
I look at him in horror as my stomach churns.
"There was no history!" I blurt. "It took me 45 minutes to get a chief complaint!" My final defense--blame the nurse: "She was triaged to the lowest acuity! The chief complaint was 'don't feel well'!"
We upgraded the patient to the resuscitation area and activated the stroke team. I was struck by the ridiculous absurdity of this sudden rush to action, given that this patient had been docilely parked in a far corner for 4 hours. Coupled with an indefinite time period, anywhere from 3-4 hours prehospital, put her well out of range of any thrombolytic or interventional therapy.
The head CT showed a large fronto-parietal infarct. The temporal sparing, ironically, is probably what prevented her being promptly diagnosed--no aphasia, and the other clue of acute onset of weakness was clouded by the confused and noncommital history.
The attending saved most of his anger for the nurse for missing the (now) obvious signs of stroke during triage. The fact that I missed it too did nothing to assuage his righteous indignation, since the nurse in question had 20+ years experience.
I am reminded of four rules I learned in surgery (okay it wasn't all bad);
1. Don't trust anybody.
2. Do it yourself.
3. Do it now.
4. Write it down.
As far as waiting to take report from EMS until the nurse is present, I'm right there with you.
Thanks for the tips!
--dex ¶ 1:46 PM 2 comments
Hulk is getting ANGRY!
J/K.
In response to Doctor, May I Have A Word?:
First off, good post by Emergiblog's Kim McAllister.
Second off, much respect.
Third--sharps. I agree wholeheartedly. I absolutely endeavor to police my sharps myself every time. I even get a little miffed if somebody wants to "help" by picking up my sharps. This messes up my count. I don't want to be stripping the bed only to find out my sharps were picked up without telling me. Anyway, go ahead and remind me. I do not mind. I will thank you for reminding me. Safety first. Go ahead and remind me to wash my hands, put in orders, finish the paperwork, too. I don't mind.
"Please let me push the drugs, doctor." I had a learning experience emphasizing this when I first pushed 5 of morphine. Silly me, I simply unplugged the I.V., fitted the syringe into the clave, and pushed 1 ml of morphine directly into the patient's hand I.V. I watched, fascinated, as the patient's arm turned bright red, creeping up from the hand. My previously AAOx3 patient said, "ooooh, I'm itchy," and again I watched in amazement my patient's rapidly deteriorating mental status. I stood there like a statue, transfixed by this metamorphosis, until a small, still voice echoed in my head--"Histamine release!". I snapped back to reality, and calmly asked the same nurse who had given me the morphine, "25 of benadryl I.V., please. Stat." The entire episode lasted about a minute, and the patient just as dramatically recovered after Benadryl was given. Lesson learned. No blood, no foul. Omerta!
So yeah, you should give the meds, nurse. Not only to avoid above rookie-type mistakes, but also for the sake of documentation.
However, don't look at me crosseyed when I want 4mg of Versed "to go," (accompanying delirious patient to MRI) or "5/2/1" mg of Haldol/Ativan/Cogentin "just in case," (okay, I'll evaluate the 250 pound gorilla in florid psychosis. No problem!) or the 20 mg of labetalol "for the road," that I want to be armed with as I escort my 92 year old pretzel with Afib/RVR to telemetry.
Sorry if I bogart the chart at times. I always try to ask. Doesn't really apply in my ER cuz we got a pretty good EHR, with patient tracking and results reporting in-line with nurse's and doctor's notes, in real time. Slam!
Respect for the triage and intake ritual. This usually isn't a problem for me--we are usually so swamped, I am 8 patients behind all the time--no chance to be chomping at the bit for more work. Almost a non sequitur where I work.
You get first crack at the new patients coming in. Believe me, I am grateful you do this--forewarned is forearmed. Vital signs are vital, as they say. In fact, unless the patient is crashing right there, I want you to spend MORE time doing this. More than once I've been blindsided by "historicus alternans," or inappropriate triage acuity.
On my last shift in the ER as an intern this year, I picked up a 65 year old with a chief complaint of "don't feel well", triaged to low acuity. The patient had been waiting 4 hours or so. The history was almost impossible to obtain--the patient was verbal and calm, but confused. Relatives were in other states, and no primary care doctor could be elicited. No significant medical history or medication list could be elicited. The only corroborating story coming from the helpful but clueless neighbor who found the patient.
The patient's answers to all my questions were noncommittal, vague, or just plain "I don't know". Unsure of what I was looking for, I proceeded with my exam, which revealed an obvious global cognitive deficit, and mild motor weaknesses in the right upper and lower extremities. Patient in no acute distress. Vital signs rock solid.
Puzzled, I presented the patient to my attending, lamely attempting a synopsis of the patient's present illness, with a working diagnosis of dementia, geared towards my plan of "social" admission until home care or nursing home placement could be arranged. As my attending stared at me in disbelief, I became painfully aware of how pathetic my assesment really was.
"Confused with unilateral weakness, huh? What's her baseline?" my attending snapped.
"Uh, she lives at home by herself."
"Do you think that lady," nodding towards the patient, "could shop? Clean? Cook for herself?"
"Uh, no."
"So it's fair to say that this is an acute change in functioning."
"Yes." I surrender!
"Did it occur to you that this patient had a stroke?"
I look at him in horror as my stomach churns.
"There was no history!" I blurt. "It took me 45 minutes to get a chief complaint!" My final defense--blame the nurse: "She was triaged to the lowest acuity! The chief complaint was 'don't feel well'!"
We upgraded the patient to the resuscitation area and activated the stroke team. I was struck by the ridiculous absurdity of this sudden rush to action, given that this patient had been docilely parked in a far corner for 4 hours. Coupled with an indefinite time period, anywhere from 3-4 hours prehospital, put her well out of range of any thrombolytic or interventional therapy.
The head CT showed a large fronto-parietal infarct. The temporal sparing, ironically, is probably what prevented her being promptly diagnosed--no aphasia, and the other clue of acute onset of weakness was clouded by the confused and noncommital history.
The attending saved most of his anger for the nurse for missing the (now) obvious signs of stroke during triage. The fact that I missed it too did nothing to assuage his righteous indignation, since the nurse in question had 20+ years experience.
I am reminded of four rules I learned in surgery (okay it wasn't all bad);
1. Don't trust anybody.
2. Do it yourself.
3. Do it now.
4. Write it down.
As far as waiting to take report from EMS until the nurse is present, I'm right there with you.
Thanks for the tips!
--dex ¶ 1:46 PM 2 comments
Thursday, December 14, 2006
Residency Spot Anxiety
I'm worried.
Worried that, come March 14th, the day of reckoning for all residency applicants, I'm going to come up bupkis.
My EM spot at Metropolis is assured, my inside guy tells me, but again, he is fickle, and who knows how much pull this guy really has?
I started worrying for real when one of my interviews, actually one of my safeties, went south because they had no spots for PGY-2's. Briefly I considered asking for an interview for a PGY-1 spot, but after the hell I went through as a rotator in Surgery, I said nothing. I've told people I wouldn't mind repeating PGY-1 in a linked program, repeating Surgery I don't want to do.
So now my eggs are pretty much all in one basket at Metropolis. I'll have to admit, it seems like a sure thing, but another intern in my program is also rotating at that ER, and she is also wants a spot there. I need a Plan B. Options. Here's what I've been thinking:
1.) Calling up the programs I didn't hear from and asking for an interview. I'm going to do this regardless.
2.) Prepare for The Scramble--several EM spots in my area went unfilled last year, so I definitely have a chance. I'd put my odds at 50-50 for this, though. Taking the USMLE ("U-Smile!") Step II, although unnecessary (I'm a D.O., and have done well on the COMLEX II), might be an ace that would tip the cards in my favor. I'll have to plan it for late Jan or early Feb in order to have the scores back in time for the Scramble. Or I could take COMLEX step III, required for licensure. Easier, and perhaps more useful given some options I've listed below.
Post-Scramble:
3.) Scramble into IM or FP. Not exactly what I want to do, but I've always enjoyed primary care. Actually, I've always thought of EM as primary care on steroids, and I mentioned my primary care skills as a strength in my personal statement. Additionally, my FP mentioned he'd like to retire soon, and intimated I'd have a practice if I went FP.
4.) Hold out for a second round of EM applications. I'd be growing a little long in the tooth for residency, and I'd have next year to fill with some kind of meaningful activity:
a.) EM research would be an obvious choice here, if I could get it. Probably would be a great resume buff to add publications and research experience in the field, especially given ACEP's mandate for research for residency accreditation.
b.) Taking Step III as mentioned above and apply for licensure. Hit the streets and try to get a job as a "physician extender," maybe in a clinic or a private office. Maybe work some connections.
c.) Medecins* Sans Frontieres: See the world, save some lives. Pros: learn another foreign language, get great experience, and who cares about money when you've got no debt and are living in a shack in Nigeria. Cons: would they even take me? I'd be licenced but not board certified. Flying back for interviews would also be difficult, not to mention expensive. Family might help out, though. Parasites and privation would be a problem, but it would demonstrate my commitment to medicine as well as humanity. Might be a valuable lesson.
d.) Join the military. As a doctor in the military, I think I'd be part of the solution versus part of the problem vis-a-vis the Iraq war, which I was wholeheartedly opposed to from the beginning. Helping out our own guys or possibly even helping out some Iraquis, I'd be doing my part. Sure it'd be dangerous. But again, it'd be a great experience, and would probably form the basis of any future residency application. Again, however, interviews might be a problem. With a little planning, it might work. However, with the ominous "stop-loss" program currently in place, the time commitment might very well be indefinite, anywhere from two years to four. I'd be a great candidate for residency, but I'd be at least 3 years out of med school, still looking for a residency spot.
Although, the military has its own system of residency training...
d.) Find work with Big Pharma or the medical device industry. Hold my nose, sell my soul. I hear the job market for doctors in medical companies is pretty good. Unpalatable, to be sure, but I gotta eat.
Related posts at SDN:
Scramble advice from a PD.
List of unfilled EM spots for 2006.
Getting interviews.
I'm not alone.
Comments?
*Changed "Docteurs" to "Medecins": Thx Dr. Couz! J'ai besoin de perfectionner mon francais!
UPDATE:Two more Interviews! Just shows to go you. I need to improve my negative capability. ¶ 2:01 PM 5 comments
Worried that, come March 14th, the day of reckoning for all residency applicants, I'm going to come up bupkis.
My EM spot at Metropolis is assured, my inside guy tells me, but again, he is fickle, and who knows how much pull this guy really has?
I started worrying for real when one of my interviews, actually one of my safeties, went south because they had no spots for PGY-2's. Briefly I considered asking for an interview for a PGY-1 spot, but after the hell I went through as a rotator in Surgery, I said nothing. I've told people I wouldn't mind repeating PGY-1 in a linked program, repeating Surgery I don't want to do.
So now my eggs are pretty much all in one basket at Metropolis. I'll have to admit, it seems like a sure thing, but another intern in my program is also rotating at that ER, and she is also wants a spot there. I need a Plan B. Options. Here's what I've been thinking:
1.) Calling up the programs I didn't hear from and asking for an interview. I'm going to do this regardless.
2.) Prepare for The Scramble--several EM spots in my area went unfilled last year, so I definitely have a chance. I'd put my odds at 50-50 for this, though. Taking the USMLE ("U-Smile!") Step II, although unnecessary (I'm a D.O., and have done well on the COMLEX II), might be an ace that would tip the cards in my favor. I'll have to plan it for late Jan or early Feb in order to have the scores back in time for the Scramble. Or I could take COMLEX step III, required for licensure. Easier, and perhaps more useful given some options I've listed below.
Post-Scramble:
3.) Scramble into IM or FP. Not exactly what I want to do, but I've always enjoyed primary care. Actually, I've always thought of EM as primary care on steroids, and I mentioned my primary care skills as a strength in my personal statement. Additionally, my FP mentioned he'd like to retire soon, and intimated I'd have a practice if I went FP.
4.) Hold out for a second round of EM applications. I'd be growing a little long in the tooth for residency, and I'd have next year to fill with some kind of meaningful activity:
a.) EM research would be an obvious choice here, if I could get it. Probably would be a great resume buff to add publications and research experience in the field, especially given ACEP's mandate for research for residency accreditation.
b.) Taking Step III as mentioned above and apply for licensure. Hit the streets and try to get a job as a "physician extender," maybe in a clinic or a private office. Maybe work some connections.
c.) Medecins* Sans Frontieres: See the world, save some lives. Pros: learn another foreign language, get great experience, and who cares about money when you've got no debt and are living in a shack in Nigeria. Cons: would they even take me? I'd be licenced but not board certified. Flying back for interviews would also be difficult, not to mention expensive. Family might help out, though. Parasites and privation would be a problem, but it would demonstrate my commitment to medicine as well as humanity. Might be a valuable lesson.
d.) Join the military. As a doctor in the military, I think I'd be part of the solution versus part of the problem vis-a-vis the Iraq war, which I was wholeheartedly opposed to from the beginning. Helping out our own guys or possibly even helping out some Iraquis, I'd be doing my part. Sure it'd be dangerous. But again, it'd be a great experience, and would probably form the basis of any future residency application. Again, however, interviews might be a problem. With a little planning, it might work. However, with the ominous "stop-loss" program currently in place, the time commitment might very well be indefinite, anywhere from two years to four. I'd be a great candidate for residency, but I'd be at least 3 years out of med school, still looking for a residency spot.
Although, the military has its own system of residency training...
d.) Find work with Big Pharma or the medical device industry. Hold my nose, sell my soul. I hear the job market for doctors in medical companies is pretty good. Unpalatable, to be sure, but I gotta eat.
Related posts at SDN:
Scramble advice from a PD.
List of unfilled EM spots for 2006.
Getting interviews.
I'm not alone.
Comments?
*Changed "Docteurs" to "Medecins": Thx Dr. Couz! J'ai besoin de perfectionner mon francais!
UPDATE:Two more Interviews! Just shows to go you. I need to improve my negative capability. ¶ 2:01 PM 5 comments
Friday, December 08, 2006
Money Shots from ER Blogs II.
Round and round we go...
OOOH!
New (to me, at least) ER blogs! More grist for the mill! Fuel to the fire! Throw another virgin into the volcano! BOHICA!
Seriously, I love coming home and warming up to a nice long session of emergent goodness. The more, the better! Always room for one more! Avast, ye wretches and wenches!
AARRRRR!
Mr. Hassel's Long Underpants -- SHAZAM! Can't believe I dint blogroll this before. Some choice tidbits:
"Life threatening problems are easier to treat than patients who arrive with high expectations and non-life threatening problems."
Amen, brother.
"I am more than just a triage doc with ACLS/PALS certification! Not that I need to convince myself of this, but it irks me that some docs really think this of ER docs."
Yeah, we're just glorified triage nurses, or stuck in intern year the rest of our careers. What's that, you say? Difficulty breathing? No sweat. You finally got those rock-hard abs you wanted, but the peritonitis got you down? Relax. Started your patient on Celexa and now he's blowing a deer rifle? Chill. Your patient will be here in the morning. Go back to sleep.
Trauma Queen -- "I stand in the middle of the weirdest shit, big heavy scary stuff, the dead and dying, people who've "not been seen in ages" who we find festering on their mattresses, surrounded by a stained outline that saves the police some chalk, people who've slashed their wrists in the midst of a houseful of screaming relatives."
Some potent prose there, pal.
Hallway Four -- "One interesting thing that happened during the past month is that I did my first solo intubation."
Yay!
"Once you’ve paralyzed someone, they are completely dependent on you to breath for them, so if, for some reason, you can’t breath for them, they will die."
Simple does not equal easy, eh?
Remember, air going in and out, blood going round and round.
"...the intubation went off without a hitch and we got her on a ventilator and her 02 sats improved and she stabilized and went to the ICU a few hours later."
Congrats!
Now do it 10,000 more times. Retire. Tatoo "DNR/DNI" to your chest. Await celestial discharge.
Richard Winters, M.D. -- A diamond in the rough. Great stuff from start to finish. Too many delicious pithy morsels to list, but here's a few...
"Dear Sir:
Congratulations! You got the job! That is probably what you were hoping this letter would say. But it doesn't, because you didn't.
Sincerely,
Personnel Department"
Yuk, yuk, yuk. Sob.
"I think Taser should consider making a defibrillator gun.
I'd like to be able to defibrillate someone while standing 30 feet away.
I'd see v-fib on the monitor.
I'd whip out the Taser Defibrillator Gun.
I'd shout "CLEAR!"
The patient would wake with a jolt of biphasic joules.
Of course, I might miss and hit a nurse.
That might hurt nursing recruiting."
[Grin]
"I see a fair amount of people who present as RTT with BBB.
Rata-Tat-Tat with a Baseball Bat."
I'll add it to the list.
KnifeMan -- "I had to move 'small bowel obstruction' out, and off to theatre, hope that 'stridor' would hold her own for a bit. That gave me the chance to see 'dislocated ankle' (with bonus 'altered conscious level') and pull the offending limb; once that was done, we whipped in 'dislocated hip' - lots of pain, very anxious - albeit with no real success.
This calm procession was interrupted by 'acute lower GI bleed (?perf)' man, and his party trick, "the vaso-vagal". Once MY pulse normalised, I was able to attend to 'young fractured wrist' , 'large scalp lac kid' and the re-do ankle manip. In the background was a poor unfortunate lady with a broken hip. To add insult to her, already substantial, injury, her heart kept trying to give out on her.
Time for a deep breath."
Bread and butter, man...bread and butter.
Trench Doc -- Intern stories:
"While the intern was performing a rectal on a teenage female, the nurse decided to help the young girl by saying, “If you don’t relax, it’s not going to feel as good.”
Wink, wink. Nudge, nudge.
"Say no more!"
"While attempting to reduce a priapism (pathologically engorged penis) an intern noted, “hmm, you know this is the first time I’ve ever held a man’s erect penis in my hand… it feels weird.” The patient was unimpressed."
Like this --> :-|
Or this --> :-/
"An intern, quite full of himself, yelled at a nurse, “why hasn’t the patient gotten the tylenol I ordered”…
Nurse- “you ordered it to be given IV.”
Intern- “that’s damn right, and that was 20 minutes ago”
Nurse- “yes, and just like 20 minutes ago, tylenol still only comes in pills”
HA HA! Stupid intern!
[Rushes off to change IV Tylenol orders.]
More later.
That's all folks!
-dex ¶ 7:26 PM 0 comments
Round and round we go...
OOOH!
New (to me, at least) ER blogs! More grist for the mill! Fuel to the fire! Throw another virgin into the volcano! BOHICA!
Seriously, I love coming home and warming up to a nice long session of emergent goodness. The more, the better! Always room for one more! Avast, ye wretches and wenches!
AARRRRR!
Mr. Hassel's Long Underpants -- SHAZAM! Can't believe I dint blogroll this before. Some choice tidbits:
"Life threatening problems are easier to treat than patients who arrive with high expectations and non-life threatening problems."
Amen, brother.
"I am more than just a triage doc with ACLS/PALS certification! Not that I need to convince myself of this, but it irks me that some docs really think this of ER docs."
Yeah, we're just glorified triage nurses, or stuck in intern year the rest of our careers. What's that, you say? Difficulty breathing? No sweat. You finally got those rock-hard abs you wanted, but the peritonitis got you down? Relax. Started your patient on Celexa and now he's blowing a deer rifle? Chill. Your patient will be here in the morning. Go back to sleep.
Trauma Queen -- "I stand in the middle of the weirdest shit, big heavy scary stuff, the dead and dying, people who've "not been seen in ages" who we find festering on their mattresses, surrounded by a stained outline that saves the police some chalk, people who've slashed their wrists in the midst of a houseful of screaming relatives."
Some potent prose there, pal.
Hallway Four -- "One interesting thing that happened during the past month is that I did my first solo intubation."
Yay!
"Once you’ve paralyzed someone, they are completely dependent on you to breath for them, so if, for some reason, you can’t breath for them, they will die."
Simple does not equal easy, eh?
Remember, air going in and out, blood going round and round.
"...the intubation went off without a hitch and we got her on a ventilator and her 02 sats improved and she stabilized and went to the ICU a few hours later."
Congrats!
Now do it 10,000 more times. Retire. Tatoo "DNR/DNI" to your chest. Await celestial discharge.
Richard Winters, M.D. -- A diamond in the rough. Great stuff from start to finish. Too many delicious pithy morsels to list, but here's a few...
"Dear Sir:
Congratulations! You got the job! That is probably what you were hoping this letter would say. But it doesn't, because you didn't.
Sincerely,
Personnel Department"
Yuk, yuk, yuk. Sob.
"I think Taser should consider making a defibrillator gun.
I'd like to be able to defibrillate someone while standing 30 feet away.
I'd see v-fib on the monitor.
I'd whip out the Taser Defibrillator Gun.
I'd shout "CLEAR!"
The patient would wake with a jolt of biphasic joules.
Of course, I might miss and hit a nurse.
That might hurt nursing recruiting."
[Grin]
"I see a fair amount of people who present as RTT with BBB.
Rata-Tat-Tat with a Baseball Bat."
I'll add it to the list.
KnifeMan -- "I had to move 'small bowel obstruction' out, and off to theatre, hope that 'stridor' would hold her own for a bit. That gave me the chance to see 'dislocated ankle' (with bonus 'altered conscious level') and pull the offending limb; once that was done, we whipped in 'dislocated hip' - lots of pain, very anxious - albeit with no real success.
This calm procession was interrupted by 'acute lower GI bleed (?perf)' man, and his party trick, "the vaso-vagal". Once MY pulse normalised, I was able to attend to 'young fractured wrist' , 'large scalp lac kid' and the re-do ankle manip. In the background was a poor unfortunate lady with a broken hip. To add insult to her, already substantial, injury, her heart kept trying to give out on her.
Time for a deep breath."
Bread and butter, man...bread and butter.
Trench Doc -- Intern stories:
"While the intern was performing a rectal on a teenage female, the nurse decided to help the young girl by saying, “If you don’t relax, it’s not going to feel as good.”
Wink, wink. Nudge, nudge.
"Say no more!"
"While attempting to reduce a priapism (pathologically engorged penis) an intern noted, “hmm, you know this is the first time I’ve ever held a man’s erect penis in my hand… it feels weird.” The patient was unimpressed."
Like this --> :-|
Or this --> :-/
"An intern, quite full of himself, yelled at a nurse, “why hasn’t the patient gotten the tylenol I ordered”…
Nurse- “you ordered it to be given IV.”
Intern- “that’s damn right, and that was 20 minutes ago”
Nurse- “yes, and just like 20 minutes ago, tylenol still only comes in pills”
HA HA! Stupid intern!
[Rushes off to change IV Tylenol orders.]
More later.
That's all folks!
-dex ¶ 7:26 PM 0 comments
Thursday, December 07, 2006
Emergency--What Does It Mean?
From the 30 tabs I've got open all relating to EM.
Saturday call tomorrow. The worst.
Cake plays in the background:
Sad songs
and waltzes
aren't selling
this year.
Time to get the eye on the prize--EM residency.
Immerse myself in it, and forget my suffering.
"He who has a why to live, can bear almost any how." --Nietzsche.
So, a little exercise to remind myself of joy.
Free association/Google treasure hunt to "Emergency"--Go!
Charity Doc's -- lawsuit woes--respect medicine--fear is your ally--a doctor with a reputation for safety or for recklessness?
GruntDoc -- still having fun after all these years.
Kim -- my teammate, my comrade, my right hand.
Shadowfax -- You are judged by how you treat those lower than you. Go Dems! Don't let me down. Obama for President!
Nick Genes -- Fellow ER res. The first ER blog I read. I read all his posts. Organized Grand Rounds, fer chrissakes. Props, man. Let's have a beer.
Central Computah -- a salty ER nurse. I feel like I know him, like he's in my crew. Tells great f'in stories. He would tell this story better than me:
Pt: "What do you mean I can't see my doctor! I'm in pain!"
Platypus: "Doctor's busy. You twisted your ankle playing weekend warrior. It's 3AM. You got pain medicine a half-hour ago. You're obnoxious. Citizens with real emergencies get treated. Trolls who waste our time wait."
Pt: "WHAT! How dare you! I'll have your ass! I know people! I'm litigious! Do you know who I am?"
Platypus [over his shoulder]: "Hey guys, he doesn't know who he is. Get the leathers--he's moving to the psych holding area. Seems he's suffering from acute Vitamin H deficiency."
Aw yeah.
Scalpel -- Dad? Is that you? My blog Attending.
Panda Bear -- Yo, dude. Solid. Part medical travelloguer, part ER God. Mad Props.
Cadeuceus -- Good writer. How about a new post once in a while. Mark Foley is SOO October. MORE! Dictate a post to your resident, I don't care! I want more!
Dr. Couz -- Makes me want to move back to Canada--yes, I'm a Canuck. I'm politer than you! ER Docs got it good in Canada. I got a sneaking suspicion the Canadian medical system is the bomb. And don't whine about no MRI's when you can just crawl across the border and pay for it yourself, you need it so bad. At least Canada has a functioning and respected primary care system. There they understand that docs aren't greedy, they just want to make enough not to worry about money so they can focus on patient care. Of course this type of system is subject to abuses, like in the UK where the system is a cruel joke. If Kafka and Ayn Rand had ever collaborated, their most fiendish allegory of apocalypse by bureaucracy would be canonized as gospel by the parasites at the top of the NHS.
Tyson Lewis -- The fire in your heart is out. You are an artist as a writer. How it must hurt you not to practice your art. Please post more. Pretty please?
[At this point I just googled "Emergency" to invite serendipity in for a chat.]
Meditations in an Emergency -- And I thought my paragraphs were long. Dude. Trim. It. Down. Read some Hemingway. Brevity is the soul of wit, like the wise man say. Next.
Emergency Medicine Journal -- Hmm. Interesting, if a bit busy. Where's, like, the content? Bookmarked for further review-------------->
Emergency.blog -- unfortunately, the prime www real estate is inhabited by a crackpot. I'd be more likely to be asking this guy about why the CIA wants to kill him while wondering if his tinfoil hat could be used as a weapon.
Wonkette -- The venerable. Not really EM relevant. Katherine Harris--TOBASH, yeah, but is this really an emergency? More like a sad inevitability. I guess it's actually a painfully true commentary of EM. "Emergency" seems to have lost some of its urgency, neh?
Baby Toolkit --In contrast to the myopic hysterics of the polymorphous perversity squatting at emergenc y .com (purposely misspelled to avoid backlinking), the eminently sensible syllogisms of citizengeek shine like diamonds. Overtly wrapping itself in the
ancient stereotype of geeks as useless techno-fetishists, this blog seeks to propogate the association of "geek" with masculine competence and power. Associating "geek" with the Godfatherish qualities of problem-solver, deal-maker, or "Fixer" flies in the face of traditional high-school impressions of ineptitude, misunderstood obsessions, and pathetic meltdown under any kind of stress--a reputation for calm effectiveness being nigh anathema. But when the wheel of fortune deals you instant karma, who better to rely upon than the emergency geek?
NNSeek -- The politics of triage. "Triage" in EM-speak is almost an article of faith. Failure at the top results in a bad situation turning into a disaster. This little editorial shows that Dear Leader should have an ER Doc as Chief of Staff.
docuticker -- Dextromethorphan is a little-recognized OTC opiate used as a cough suppressant. Needless to say, lots of it ==> ER visit for some Narcan.
"An estimated 12,584 emergency department (ED) visits involved pharmaceuticals containing dextromethorphan (DXM). This was 0.7 percent of all drug-related ED visits."
And sudafed is restricted???
Lifehacker -- More on non-medical emergencies, this time from one of my favorite sites. A winter road-kit. Duh. Do it yourself, dude. Seems that preparation and a judicious aforesight re: your anticipated environment/situation is a common theme for mitigating emergencies. [Strokes chin thoughtfully].
Emergency.com -- Hey waitaminit! I thought I had already relegated this site to the dustbin! Seems the parent site/portal is a lot better than the blog. Unfortunately outdated--the table of contents has "Y2K" and "Bosnia" as glaring anachronisms justifying safely relegating this site to another google dead-end.
FEMA -- the case study of Bush's leadership failure. Yes it's his fault. Interesting deep-links for the attention-deficient:
Grants and Assistance Programs for Emergency Personnel
Protect Your Family and Property
Prepare for Hazards
"Emergency!" -- Eh. Google delivers what people link to. "You'll never go broke underestimating the intelligence of the American people" --P.T. Barnum.
This post is way too long. I'll stop with a gem:
eMedicine EM reference -- eMedicine delivers. Again. 'Nuff said. Go forth and learn. ¶ 8:18 PM 6 comments
From the 30 tabs I've got open all relating to EM.
Saturday call tomorrow. The worst.
Cake plays in the background:
Sad songs
and waltzes
aren't selling
this year.
Time to get the eye on the prize--EM residency.
Immerse myself in it, and forget my suffering.
"He who has a why to live, can bear almost any how." --Nietzsche.
So, a little exercise to remind myself of joy.
Free association/Google treasure hunt to "Emergency"--Go!
Charity Doc's -- lawsuit woes--respect medicine--fear is your ally--a doctor with a reputation for safety or for recklessness?
GruntDoc -- still having fun after all these years.
Kim -- my teammate, my comrade, my right hand.
Shadowfax -- You are judged by how you treat those lower than you. Go Dems! Don't let me down. Obama for President!
Nick Genes -- Fellow ER res. The first ER blog I read. I read all his posts. Organized Grand Rounds, fer chrissakes. Props, man. Let's have a beer.
Central Computah -- a salty ER nurse. I feel like I know him, like he's in my crew. Tells great f'in stories. He would tell this story better than me:
Pt: "What do you mean I can't see my doctor! I'm in pain!"
Platypus: "Doctor's busy. You twisted your ankle playing weekend warrior. It's 3AM. You got pain medicine a half-hour ago. You're obnoxious. Citizens with real emergencies get treated. Trolls who waste our time wait."
Pt: "WHAT! How dare you! I'll have your ass! I know people! I'm litigious! Do you know who I am?"
Platypus [over his shoulder]: "Hey guys, he doesn't know who he is. Get the leathers--he's moving to the psych holding area. Seems he's suffering from acute Vitamin H deficiency."
Aw yeah.
Scalpel -- Dad? Is that you? My blog Attending.
Panda Bear -- Yo, dude. Solid. Part medical travelloguer, part ER God. Mad Props.
Cadeuceus -- Good writer. How about a new post once in a while. Mark Foley is SOO October. MORE! Dictate a post to your resident, I don't care! I want more!
Dr. Couz -- Makes me want to move back to Canada--yes, I'm a Canuck. I'm politer than you! ER Docs got it good in Canada. I got a sneaking suspicion the Canadian medical system is the bomb. And don't whine about no MRI's when you can just crawl across the border and pay for it yourself, you need it so bad. At least Canada has a functioning and respected primary care system. There they understand that docs aren't greedy, they just want to make enough not to worry about money so they can focus on patient care. Of course this type of system is subject to abuses, like in the UK where the system is a cruel joke. If Kafka and Ayn Rand had ever collaborated, their most fiendish allegory of apocalypse by bureaucracy would be canonized as gospel by the parasites at the top of the NHS.
Tyson Lewis -- The fire in your heart is out. You are an artist as a writer. How it must hurt you not to practice your art. Please post more. Pretty please?
[At this point I just googled "Emergency" to invite serendipity in for a chat.]
Meditations in an Emergency -- And I thought my paragraphs were long. Dude. Trim. It. Down. Read some Hemingway. Brevity is the soul of wit, like the wise man say. Next.
Emergency Medicine Journal -- Hmm. Interesting, if a bit busy. Where's, like, the content? Bookmarked for further review-------------->
Emergency.blog -- unfortunately, the prime www real estate is inhabited by a crackpot. I'd be more likely to be asking this guy about why the CIA wants to kill him while wondering if his tinfoil hat could be used as a weapon.
Wonkette -- The venerable. Not really EM relevant. Katherine Harris--TOBASH, yeah, but is this really an emergency? More like a sad inevitability. I guess it's actually a painfully true commentary of EM. "Emergency" seems to have lost some of its urgency, neh?
Baby Toolkit --In contrast to the myopic hysterics of the polymorphous perversity squatting at emergenc y .com (purposely misspelled to avoid backlinking), the eminently sensible syllogisms of citizengeek shine like diamonds. Overtly wrapping itself in the
ancient stereotype of geeks as useless techno-fetishists, this blog seeks to propogate the association of "geek" with masculine competence and power. Associating "geek" with the Godfatherish qualities of problem-solver, deal-maker, or "Fixer" flies in the face of traditional high-school impressions of ineptitude, misunderstood obsessions, and pathetic meltdown under any kind of stress--a reputation for calm effectiveness being nigh anathema. But when the wheel of fortune deals you instant karma, who better to rely upon than the emergency geek?
NNSeek -- The politics of triage. "Triage" in EM-speak is almost an article of faith. Failure at the top results in a bad situation turning into a disaster. This little editorial shows that Dear Leader should have an ER Doc as Chief of Staff.
docuticker -- Dextromethorphan is a little-recognized OTC opiate used as a cough suppressant. Needless to say, lots of it ==> ER visit for some Narcan.
"An estimated 12,584 emergency department (ED) visits involved pharmaceuticals containing dextromethorphan (DXM). This was 0.7 percent of all drug-related ED visits."
And sudafed is restricted???
Lifehacker -- More on non-medical emergencies, this time from one of my favorite sites. A winter road-kit. Duh. Do it yourself, dude. Seems that preparation and a judicious aforesight re: your anticipated environment/situation is a common theme for mitigating emergencies. [Strokes chin thoughtfully].
Emergency.com -- Hey waitaminit! I thought I had already relegated this site to the dustbin! Seems the parent site/portal is a lot better than the blog. Unfortunately outdated--the table of contents has "Y2K" and "Bosnia" as glaring anachronisms justifying safely relegating this site to another google dead-end.
FEMA -- the case study of Bush's leadership failure. Yes it's his fault. Interesting deep-links for the attention-deficient:
Grants and Assistance Programs for Emergency Personnel
Protect Your Family and Property
Prepare for Hazards
"Emergency!" -- Eh. Google delivers what people link to. "You'll never go broke underestimating the intelligence of the American people" --P.T. Barnum.
This post is way too long. I'll stop with a gem:
eMedicine EM reference -- eMedicine delivers. Again. 'Nuff said. Go forth and learn. ¶ 8:18 PM 6 comments
Monday, December 04, 2006
Oh, Fickle Fate!
X-posted from my comment to Scalpel's post My Second Lawsuit.
I very recently had a similar situation. I am a rotating intern covering a surgical service. One of my general surgery attendings routinely operates on very sick patients. R.R. was very sick with recurrent acute cholecystitis and a history of being 5 years s/p double mastectomy for breast cancer. She also had brittle diabetes, requiring 40 units of Lantus twice a day, 25 units of Aspart before meals, and still hit 300mg/dl at least once a day.
Mr. R. was an active member of the community and a member of the hospital board. From 25 years of involvement in the hospital he had some knowledge of medicine, and he would routinely barge into the nursing station demanding this work-up, that consult, and the other expensive, irrelevant, time-consuming radiology study. They all turned up normal, including an extensive cardiac work up along with innumerable ekg's and serial enzymes. 2 weeks after admission the patient finally underwent laparoscopic cholecystectomy. She did well immediately post-op and was tolerating a full diet by POD#3. Everyone cheered, high fives all around and the seniors quietly disengaged themselves, leaving me and another intern to mop up the leftovers and discharge the patient post haste.
Mr.R finally relented from his Munchausen-by-proxy and agreed to a discharge plan after several days of continual reassurance by myself and the team as to Mrs. R's satisfactory recovery.
On a fateful Friday I rounded on the patient with only a preoccupied 2nd year supervising, as both senior residents and the attending were elbows deep in emergency surgeries. The patient was complaining of mild chest pain, and I could see she was a mildly of breath. We dismissed these as chronic, for the patient had had thorough workups for both issues. "Just get her out," my 2nd year whispered as we left the room. I acknowledged his meaninful stare with a vigorous nodding, and rushed off to finish the paperwork.
Mr. T., undeterred, called our attending, and demanded a pulmonary consult. 2 hours later, discharge instructions in hand, I reviewed the 2-day old CXR with the pulmonologist. I excitedly pointed out the mild cephalization, and Mr.R angrily pointed out a mild R effusion, which we had previously dismissed as sympathetic, with atelectasis. The distinguished lung doc summed up our observations, mildly pointing out the elephant in the living room--"She's in CHF".
"This is new," I thought to myself. Uh-oh.
In a mild voice, the consultant suggested sligtly increasing the lasix, repeating the chest x-ray, and matter-of-factly recommended a cardiology follow-up. He left in a hurry without leaving a note.
That left me (feeling nauseous) and Mr.R (visibly approaching critical mass) staring at each other in silence. I excused myself to call the cardiologist, double-time. The day was a-wastin', and I quickly put in for an EKG while paging the cardiologist.
The team assembled soon after. The EKG and the cardiologist arrived at the same time, and we grudgingly conceded the obvious display of a-fib with RVR. We reluctantly got yet another set of cardiac enzymes. Mr. R, while not talking to various Important People on the phone, glowered at us accusingly. CHIEF RESIDENT said to my co-intern, "now, see...where you see defeat, I see opportunity."
We brought up the idea of a transfer to medicine under the cardiologist's service, but Mr.R refused. We were astonished, but went about transferring the patient to our telemetry unit. I went home, elated that I had not been blamed. I told myself this was another false alarm, and started drinking.
Two days later I returned, grateful to find the patient had been transferred to the cardiologist's service. A Pyrrhic victory. My joy curdled when I saw the patient. In the MICU. Intubated. Transmural MI. Mitral valve rupture. Shit.
I conveyed my sincere condolences to Mr.R and left, dismayed by her clinical free-fall from stable, to fair, to guarded, to poor, to critical, in the space of essentially one 24 hour period.
Mr. R naturally wanted heads to roll, and settled his sights on CHIEF RESIDENT, and curiously, on my co-intern. Seems my co-intern, an actual surgical intern, and a damn good one, had lost it the night previously to the disaster, and had rudely dismissed all of Mr.T.'s endless criticisms and complaints, saying she was fine and would be discharged the following morning at the earliest opportunity. Mr. R blamed the intern for the entire debacle.
Strangely, Mr. T. had developed an inexplicable affection for me, going so far as to write a letter of recommendation for me to the head of the EM department through his innumerable back channels. He told me my residency spot next year was a done deal. Not only was it in the same breath as saying my co-intern would be sacked after his meeting with the chair of surgery, but I hadn't even interviewed yet. I was dumbstruck.
The whole thing is extremely weird and terrifying to me. My supposedly stable patient suffered a massive post-op MI under my nose, and I ignored the red flags my conscience raised because I was afraid of displeasing CHIEF RESIDENT. Thank God Mr.T. had the balls not to allow his wife to be discharged. I'm really frustrated by his wife's decompensation, but at the same time I'm thrilled to have such a powerful ally. I'm a bit uneasy about it, though--TAANSTAFL. My career depends on the whims of a cantankerous godfather like this? Yeesh.
-dex ¶ 7:59 PM 0 comments
X-posted from my comment to Scalpel's post My Second Lawsuit.
I very recently had a similar situation. I am a rotating intern covering a surgical service. One of my general surgery attendings routinely operates on very sick patients. R.R. was very sick with recurrent acute cholecystitis and a history of being 5 years s/p double mastectomy for breast cancer. She also had brittle diabetes, requiring 40 units of Lantus twice a day, 25 units of Aspart before meals, and still hit 300mg/dl at least once a day.
Mr. R. was an active member of the community and a member of the hospital board. From 25 years of involvement in the hospital he had some knowledge of medicine, and he would routinely barge into the nursing station demanding this work-up, that consult, and the other expensive, irrelevant, time-consuming radiology study. They all turned up normal, including an extensive cardiac work up along with innumerable ekg's and serial enzymes. 2 weeks after admission the patient finally underwent laparoscopic cholecystectomy. She did well immediately post-op and was tolerating a full diet by POD#3. Everyone cheered, high fives all around and the seniors quietly disengaged themselves, leaving me and another intern to mop up the leftovers and discharge the patient post haste.
Mr.R finally relented from his Munchausen-by-proxy and agreed to a discharge plan after several days of continual reassurance by myself and the team as to Mrs. R's satisfactory recovery.
On a fateful Friday I rounded on the patient with only a preoccupied 2nd year supervising, as both senior residents and the attending were elbows deep in emergency surgeries. The patient was complaining of mild chest pain, and I could see she was a mildly of breath. We dismissed these as chronic, for the patient had had thorough workups for both issues. "Just get her out," my 2nd year whispered as we left the room. I acknowledged his meaninful stare with a vigorous nodding, and rushed off to finish the paperwork.
Mr. T., undeterred, called our attending, and demanded a pulmonary consult. 2 hours later, discharge instructions in hand, I reviewed the 2-day old CXR with the pulmonologist. I excitedly pointed out the mild cephalization, and Mr.R angrily pointed out a mild R effusion, which we had previously dismissed as sympathetic, with atelectasis. The distinguished lung doc summed up our observations, mildly pointing out the elephant in the living room--"She's in CHF".
"This is new," I thought to myself. Uh-oh.
In a mild voice, the consultant suggested sligtly increasing the lasix, repeating the chest x-ray, and matter-of-factly recommended a cardiology follow-up. He left in a hurry without leaving a note.
That left me (feeling nauseous) and Mr.R (visibly approaching critical mass) staring at each other in silence. I excused myself to call the cardiologist, double-time. The day was a-wastin', and I quickly put in for an EKG while paging the cardiologist.
The team assembled soon after. The EKG and the cardiologist arrived at the same time, and we grudgingly conceded the obvious display of a-fib with RVR. We reluctantly got yet another set of cardiac enzymes. Mr. R, while not talking to various Important People on the phone, glowered at us accusingly. CHIEF RESIDENT said to my co-intern, "now, see...where you see defeat, I see opportunity."
We brought up the idea of a transfer to medicine under the cardiologist's service, but Mr.R refused. We were astonished, but went about transferring the patient to our telemetry unit. I went home, elated that I had not been blamed. I told myself this was another false alarm, and started drinking.
Two days later I returned, grateful to find the patient had been transferred to the cardiologist's service. A Pyrrhic victory. My joy curdled when I saw the patient. In the MICU. Intubated. Transmural MI. Mitral valve rupture. Shit.
I conveyed my sincere condolences to Mr.R and left, dismayed by her clinical free-fall from stable, to fair, to guarded, to poor, to critical, in the space of essentially one 24 hour period.
Mr. R naturally wanted heads to roll, and settled his sights on CHIEF RESIDENT, and curiously, on my co-intern. Seems my co-intern, an actual surgical intern, and a damn good one, had lost it the night previously to the disaster, and had rudely dismissed all of Mr.T.'s endless criticisms and complaints, saying she was fine and would be discharged the following morning at the earliest opportunity. Mr. R blamed the intern for the entire debacle.
Strangely, Mr. T. had developed an inexplicable affection for me, going so far as to write a letter of recommendation for me to the head of the EM department through his innumerable back channels. He told me my residency spot next year was a done deal. Not only was it in the same breath as saying my co-intern would be sacked after his meeting with the chair of surgery, but I hadn't even interviewed yet. I was dumbstruck.
The whole thing is extremely weird and terrifying to me. My supposedly stable patient suffered a massive post-op MI under my nose, and I ignored the red flags my conscience raised because I was afraid of displeasing CHIEF RESIDENT. Thank God Mr.T. had the balls not to allow his wife to be discharged. I'm really frustrated by his wife's decompensation, but at the same time I'm thrilled to have such a powerful ally. I'm a bit uneasy about it, though--TAANSTAFL. My career depends on the whims of a cantankerous godfather like this? Yeesh.
-dex ¶ 7:59 PM 0 comments
